Although it is fair to say that preventative medicine
has neglected men in the last 50 years even though they die 7 years on
average earlier than women, traditional treatment over the centuries has
focussed upon men and male virility. Even from Egyptian days 4000 years
ago the interest in what we will now call "endocrinology"
was based upon improving the sex life of men and avoiding pregnancy
in women. There were all sorts of weird ways of preventing pregnancy,
the most famous and eccentric being a vaginal pessary of honey and
crocodile dung but for the men the secret seemed to be the eating
of testicles of various animals recognising that puberty, virility
and fertility were somehow related to these organs.

In the last 19th century, Brown Sequard, a distinguished
French physician and the founder of endocrinology created a cocktail
of sheep's testis which he claimed improved his mental ability,
energy and "increased the arc of his urine". There were many such
other anecdotal and non-scientific claims over the next half century.
The male hormone, testosterone, was believed to be the vital chemical
and the isolation of testosterone was a race between scientists
from the companies Organon, Schering and Ciba. It was isolated in
1935 with the Nobel Prize for Medicine going to the Organon scientists.
The clinical trials of testosterone starting two years later were
mostly on women for no other reason than that the principal doctors
interested in the new hormones, oestrogen and testosterone, were
gynaecologists. When it was possible to measure these hormones it
became clear that testosterone existed in women as well as men but
in lesser amounts and even existed in normal young women in levels
twice as high as the traditionally recognised female hormone, oestrogen.
It is thus untrue to think that testosterone is a male hormone.
Oestrogen and testosterone are both hormones and treatment with
either or both hormones may be appropriate for men or women.

The role of testosterone in women is now clearly
established but it is regrettable that in spite of the logic for
its use in men and in some circles, and enthusiasm for such treatment,
there are very, very few scientific trials to support its use. Logically
it should be hugely beneficial but we need clinical trials to convince
the sceptics in the same way it was necessary 30 years ago to conduct
proper trials on oestrogen to firmly establish which were the symptoms
of oestrogen deficiency and which were the result of ageing or disease
and independent of any hormone levels.

The ageing male usually has a decrease in testosterone
but not as invariably as in women whose plasma oestrogen levels
always decline at the time of the menopause. There are also increasing
problems with health with age and the dilemma is to decide whether
these changes are [1] determined by age, genetics and lifestyle
factors or [2] whether there is a hormonal component to these disorders
which is coincidental and does not respond to treatment and [3]
whether there is a treatable hormonal component that will prevent
or ameliorate many of the symptoms and illnesses of the ageing male.

So far a couple of acronyms have been devised :-
ADAM - Androgen Decline in the Ageing Male or PEDAM - the Partial
Endocrine Deficiency in the Adult Male. Most 60 year old men, the
author included, would rather be regarded as "adult" than "ageing".
My feeling is that PEDAM wins this competition even if only for
the choice of a kinder adjective.

Although living longer, there is a greater period
of dependency. In 1927 the average life span was around 47 years
and death resulted usually from acute disease or trauma. Hospitalisation
and/or dependency lasted only days of at the most weeks. In 1950
the average life span was about 58 years and hospitalisation or
dependency lasted for weeks or months. In 1999 the average life
span is about 80 years and death results from long-term chronic
diseases such as cancer, degenerative diseases, or organ failure.
Hospitalisation or dependency in 1999 may last for many years.

Thus there is the greatly increased life expectancy
in the Western world with a slightly increased health expectancy.
In the UK this is 71.8 and 58.7 years respectively giving an average
13 years of less than good health. In the USA the difference is
14.6 years of physical decline and less than healthy life. The major
health problems are cardiovascular disease including coronary artery
disease and heart failure and strokes. Various forms of cancer are
another major problem. Lung cancer has the highest mortality, also
common are stomach, liver, colon, rectum, oesophagus and also the
prostate which has the highest prevalence in old age. The chronic
disabling conditions with age include the decline in most physiological
functions, ageing of the male endocrine system, problems with prostatic
hypertrophy with urine/bladder problems. There is also erectile
dysfunction and decreased sexuality. There is osteoporosis and also
a decrease in muscle mass. Problems of mental health are more common
with dementia occurring in 4-7% of men over the age of 65 and depression
occurring in 10-15% with about 3% having severe depression. Suicide
is more common. There are sleep disorders of insomnia, early waking
and sleep apnoea. As in the female menopause, the challenge is to
find out how many of these things are related to hormonal changes
and can perhaps be treated or prevented by testosterone therapy.

There is a decline in testosterone levels particularly
the free (active) testosterone with age. The normal values of total
testosterone are between 11 and 30 nmol/l and testosterone levels
below this normal range occur in 20% of men aged 60-80 and 33% aged
over 80.

It is believed that testosterone levels of about
11nmol/l are critical for sexual function. These low levels are
also related to decline in stamina and muscle mass. It is for this
body building function that younger athletes often take testosterone
or other anabolic steroids illegally. It certainly works for them
but the evidence is less clear whether the aged male has an improvement
in body mass when he takes more modest physiological doses of testosterone.
Apart from ageing there is also evidence that stress, both physical
and psychological, excess alcohol, excess smoking, and obesity all
lower testosterone levels.

The symptoms of low testosterone in ageing/adult
men are typically flushes and sweats, depression, nervousness and
insomnia. There is also decreased libido and problems with maintaining
an erection. The men are easily fatigued, have poor concentration
and memory and complain of being easily cross and bad tempered.
Yes, there are many reasons for all of these varied problems and
just as in the female menopause it is important to tease out those
symptoms due to hormone deficiency and those due to personality,
environment, bad marriage, or other items of physical or mental
pathology. Unfortunately the clinical trial on the alleged symptoms
of the male climacteric and the response to testosterone have not
been done - nor, I think, has it even been attempted seriously.

Let us now consider testosterone and heart attacks.
It is an old joke that testosterone causes world wars and heart
attacks because allegedly it produces aggression and, as more men
have heart attacks than women, the assumption is that it is due
to testosterone. I am not sure whether either part of this statement
is correct. Over the last five years there has been so much work
showing an association of low testosterone levels in men with coronary
artery disease as shown by clinical heart attacks or by radiological
angiographic studies. This does not mean that the association is
causative as there is no proof that the low testosterone causes
the coronary heart disease but we can, I think, now exclude the
view that high testosterone is associated with heart attacks and
that testosterone, either the man's own testosterone or treatment
with testosterone, produces more heart attacks. This work comes
from Italy, from Bristol, from Leeds and is very highly regarded.
It is turning our views on hormones and heart attacks in the male
upside down.

Peter Collins from the Brompton Hospital has been
studying the effects of oestrogens on the physiology of the coronary
arteries in women showing that addition of oestrogen dilates the
coronary arteries and increases coronary blood flow. To his surprise,
the same thing occurred when testosterone was added to this experimental
model and he has now shown that testosterone dilates the coronary
arteries and increases blood flow in men as well as women

Thus, I believe we can be reassured that there
is no evidence that testosterone causes heart attacks but there
is an increasing body of good scientific work indicating that testosterone
is probably protective in the male against heart attacks. It is
important that we reject the prejudice that links testosterone with
increased heart attacks as we try to determine whether testosterone
therapy in men is clinically sensible and safe in certain endocrine
disorders or for certain groups of symptoms.

What then do you do with a man who has no symptoms
of testosterone deficiency but on repeated blood tests does have
a low testosterone? Are we justified in treating him? The problem
is that if one checked the sort of blood profile in men that I measure
in women who come to my menopause clinic, one will find significant
abnormalities. These tests include haemoglobin for anaemia, liver
function, kidney function, calcium, the lipids cholesterol and triglyceride,
blood sugar as well as the hormones measuring thyroid function,
oestradiol and FSH (important for women) and testosterone and LH
important (important for men). Many men and women would have abnormal
cholesterol levels and a few would have a high blood sugar and a
few would have abnormal thyroid function. No-one would dispute that
it is important to treat those findings but what about the men with
low testosterone?

Certainly in middle aged men lifestyle changes
must be seen to be as important as any hormone therapy. This would
include loss of weight, treatment of hypertension, not smoking,
a sensible low fat diet, reduce alcohol consumption and regular
exercise. When all of these are done, do we treat men with andropausal
symptoms with testosterone and do we treat men with low testosterone
without symptoms with testosterone? I believe you do treat although
it must be said that the data are not there to support a strong
statement on this. However, it does help a lot of men and it is
probably harmless. As a gynaecologist, I do not treat too many men
but I have over the last five years treated about 40 middle aged
men with testosterone . This is apparently helpful because they
all come back every five or six months for further treatment by
a testosterone implant convinced that they feel the psychological
and physical benefit of this replacement therapy. A breakdown of
the results of 20 of these before and after therapy has been reported
to the British Menopause Society and the North American Menopause
Society by members of my team. The results show that there were
significant reductions in symptoms of depression, anxiety, libido,
erectile dysfunction, fatigue and concentration, three months after
treatment. There were no statistical differences in their symptoms
of sleep disturbances and sweats. We could also not establish a
correlation between testosterone levels and symptom improvement
but there is a need larger numbers for a worthwhile study.

One of the clear risks of testosterone therapy
is growth of any small occult prostatic cancer that might be present.
As this is such a common tumour in older men it is essential that
before giving testosterone a rectal examination is performed to
assess the size of the prostate and also the prostatic antigen,
PSA, is measured. This is a useful, but not totally reliable, screening
test for prostatic cancer. Testosterone should not be given before
a high reading is investigated by a urologist.

Hormone replacement therapy

There are several ways of replacing hormones. The
first is to stimulate the cells of the testes into producing more
testosterone by giving LH and FSH in the form of HcG (Profasi).
This is normally a pituitary hormone which in women stimulates the
ovarian follicles to grow and thus to facilitate ovulation and release
of ova. In the man it stimulates the Leydig cells of the testis
to produce testosterone.

Injections of five or ten thousand units given
each week for five weeks which may produce an increase in plasma
testosterone if the ageing testes are responsive to these stimulating
hormones. If, however, the man already has a high LH level in the
blood indicating some degree of testicular failure, it is unlikely
to be effective. This, of course, is analogous to the menopausal
woman with a high FSH who is trying to stimulate the ovary to ovulate.
No amount of extra FSH will produce more oestrogen or facilitate
ovulation in these women.

I find that an injection of testosterone proprionate,
Sustanon 250 mgs, is a useful diagnostic test dose which works within
24 hours and lasts 2-3 weeks. Taken together with the symptomatology
and the results of the hormone tests, it does give a reasonable
indication whether long-term testosterone therapy will be helpful.

Testosterone patches are about to come on to the
market but have not been very successful. The manufacturers came
up with the idea of putting the patch on the scrotum. As the scrotum
is normally a wrinkly, hairy area it is necessary to shave but the
patch often falls off. It has been shown to be fairly ineffective
in increasing plasma testosterone levels, improving symptoms or
increasing bone density. It may have a future but it will require
more efficient transfer of testosterone from the patch through the
skin and a more sensible siting of the patch on the body.

Oral testosterone is available in the form of testosterone
undeconoate (Restandol). There has always been a theoretical danger
that oral testosterone can damage the liver but the only problems
have been in female to male transexuals taking huge doses of methyltestosterone.
In the appropriate small dose, oral testosterone does not cause
liver damage. I prefer hormone implants. As with women, this is
a very simple procedure but, of course, the dose is higher - 100
mgs is the usual dose for women but men have 600-800 mgs implants.
This is the route of administration also much preferred by my patients
who will have short-term Sustanon injections followed by long-term
testosterone implants.

There are of course side-effects of any treatment
that works. An increase in heart attacks is unlikely but could be
one of them in spite of the additional fears about testosterone.
Fears that this is associated with high testosterone levels. The
one certain problem is that of polycythaemia which is an increase
in haemoglobin and total mass of red cells because of stimulation
by testostosterone of the red blood forming hormone, erythropoetin.
This has theoretical long-term problems of venous thrombosis and
may, although I have never had such a patient, require removal of
a pint of blood every two weeks by a technique called venesection.
Weight gain is theoretically a problem although this should be due
to increased muscle bulk rather than fat round the middle of the
body. Sleep apnoea is allegedly another complication of testosterone
therapy. This may develop because the loss of oxygen experienced
if men stop breathing for forty to sixty seconds during the night
can produce the polycythaemia which is also a direct complication
of testosterone therapy.

The great fear of course is a growth of a small
undiagnosed prostate cancer and this s the reason why most andrologists
are, for the timebeing, opposed to the concept of testosterone replacement
therapy. They see that an effective treatment of advanced prostate
cancer is removal of testosterone by drugs or even removal of the
testis so it seems inconceivable to them that the administration
of testosterone can be anything but dangerous for the prostate.
However, the truth of that controversy is not at all clear. For
the timebeing annual measurement of the prostatic cancer antigen
(PSA) is the best we can offer.

We are starting a proper scientific study of testosterone
which will treat about 60 men randomised into a testosterone treatment
group and placebo treatment group. The study will be of their symptoms,
hormone levels, bone density and most of all the symptoms of flushes,
sweats, insomnia, tiredness, loss of libido and erection. Many of
these men in the study will be husbands of my menopausal patients
but other interested men will be welcome to be considered for the
study. It is fair to say that as we have no funding for the study
and volunteers will be charged a modest amount to cover the costs.

In conclusion the apparent neglect of men's ageing
and sexual problems is, for the most part, our own fault. Women
have gynaecologists and are usually willing to discuss menstrual,
sexual problems with their general practitioner or their friends.
They are much better communicators than men who, on the other hand,
have great trouble discussing sexual matters without either embarrassment
or exaggeration. Perhaps men need "andrologists" to discuss all
of these health, sexual and marital issues that they normally internalise,
being far too manly to have to discuss these important issues with
a stranger. We have seen this in our studies over the last 30 years
in that women will answer the most detailed and intimate sexual
questionnaires in some of our studies on sexual response to hormone
therapy. The same questions, transcribed for male sexuality, bring
out embarrassed incomprehension. In short, men have trouble telling
the truth about their sex lives but they still need our help. It
may be in the form of testosterone replacement therapy.

For all enquiries about any of the services outlined on this
web site,
please don't hesitate to call or email.